Culturally Competent Approaches to Assessing ADHD in African American Adults and Overcoming Cultural Issues With Patients and Families

Roberta Waite, EdD, PMHCNS-BC, FAAN

Department of Doctoral Nursing, Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania

Limited data are available regarding the prevalence of ADHD among African American adults. According to one report, in the United States, an estimated 4.4% of adults have ADHD, with almost 2% of black adults having the diagnosis.1 Untreated ADHD can cause serious difficulties at work, in relationships, and with finances, but many adults in minority communities remain undiagnosed and untreated (AV 1).2

To provide culturally competent care for African American adults with ADHD, clinicians must understand the historic backdrop of psychiatry in the African American population and provide individualized assessment. Clinicians should also examine the implications of available treatment options for African American adults with ADHD.

AV 1. Barriers to Receiving ADHD Treatment Among Minorities (00:43)

Based on National Alliance on Mental Illness2

History of Psychiatry and African Americans

Exploring the historical experiences that contribute to mistrust and underutilization of mental health care services among African Americans is key if effective change is to occur. The reason that some African Americans mistrust the mental health care system is due to a troubling history of racism rooted in medical research and diagnosis.3

Before the Civil War, pseudoscience was instrumental in initiating racial myths to defend slavery in the United States by describing African Americans not only as intellectually weak but also as innately submissive.3 Because of the belief that slavery was a natural condition for African Americans, the desire to escape it was pathologized. A slave-specific disorder, drapetomania, was invented to describe slaves running away to seek freedom, destroying property on a plantation, being disobedient, talking back, fighting with their masters, or refusing to work.

After the Civil War, unethical experimentation on African Americans continued to take place, such as in the Tuskegee syphilis study, as well as sterilization without consent.3 While these are only a few of the factors associated with a fear of medicine in general among some African Americans, acknowledging this history can help clinicians understand why some African Americans believe that the diagnosis and treatment of the behavioral disorder ADHD is an attempt at social control.4 African Americans may fear misdiagnosis, labeling, or being misunderstood due to inadequate knowledge about African American culture among mental health providers.

DSM-5 and Cultural Awareness

When using the DSM to assess mental health disorders, clinicians must understand that its classification system was inherited from the 19th century European model that distinguishes diseases based on unique symptoms, etiology, course, and treatment, which were described using studies conducted mainly on middle-class white subjects.5

Psychiatric disorders, such as ADHD, however, are variably expressed across cultures. The mental health care establishment must understand the magnitude of cultural/racial differences when assessing patients for mental health concerns.6 At the same time, clinicians must avoid stereotyping, because the black population is heterogeneous and includes African American, Caribbean, and Hispanic populations.

AV 2. Domains of Cultural Formulation (00:26)

Based on the American Psychiatric Association7

The DSM-5 suggests that culture-related diagnostic issues may contribute to the lower prevalence rates of ADHD in African Americans and Latinos than in the white population.7 Cultural formulation is described as a framework for clinical evaluation to help mitigate diagnostic errors that can occur from clinicians’ assumptions about symptoms, manifestation, expression, and course (AV 2).7 The DSM-5 provides 2 Cultural Formulation Interviews, which may be administered by clinicians to the patient or an informant.

A Multifaceted Diagnostic Approach

Because no single tool or laboratory test currently exists for diagnosing ADHD, formal diagnosis should be made using evidence from the DSM, clinical assessment, rating scales, and neuropsychological tests. Clinical assessment should include symptoms, level of impairment, developmental history (including developmental comorbidities), family history, report cards, psychological testing, collateral history, as well as the individual history, including cultural and contextual factors. ADHD is classified as a neurodevelopmental disorder.7 In adults, inattention is the predominant symptom, which can include disorganization, unreliability, forgetfulness, inefficiency in planning, inability to complete tasks and trouble with task shifting, and time management issues. Hyperactivity may diminish in adults, but symptoms may include moving one’s hands and feet, feeling restless, talking excessively and interrupting others, and having poor impulse control.

The patient must have had several inattentive or hyperactivity impulsive symptoms present before age 12 years.7 Symptoms must be present in 2 or more settings (home, school, work, or social events), must interfere with or reduce the quality of functioning, and cannot be explained better by another diagnosis.

Diagnosis of ADHD typically requires informant reports.7 For many African Americans, family is their main support system, and including family members in a patient’s assessment and treatment, with the patient’s permission, may be helpful.8 On rating scales, however, patients’ and informants’ feedback is influenced by their own cultural filters and “historical concepts,” or the meaning and interpretation that individuals assign to their histories. Mental health care practitioners regularly obtain a present, past, and family history of illnesses such as ADHD from their patients. Providers must also explore patients’ and families’ historical concepts, as being “history sensitive” is a fundamental way in which providers can reduce African Americans’ cultural mistrust of the mental health care system.

Implications for Treatment

Clinicians should work closely with patients and their families to ensure that they avoid a cycle of blame, hopelessness, or self-defeating behaviors. Treatment can take the form of psychotherapy and psychopharmacology, in addition to using alternative therapies or working with a pastor.

Psychotherapy. A culturally congruent model of therapy for African Americans is the Intersystem model, which is an integrated and comprehensive model that assimilates properties from not only the individual but also interactional and intergenerational patient systems.9 This model offers a contextual framework to help assess and treat many complex problems that arise from ADHD. One of the many strengths of the Intersystem model is that it recognizes the complexity of the person’s life, relationships, and problems, and supports these multiple viewpoints.

During treatment, therapists must be aware of their own biases and explicitly confront any stereotypes they have regarding African Americans. This process should be done before and throughout the relationship with patients because if not directly confronted, microaggressions can occur.10 The patient’s race is critical, and conversation about it should not be avoided, because what is unsaid can seep into other areas of the relationship between patient and therapist. Furthermore, therapists should be cognizant of the patient’s needs and should discuss the patient’s expectations of the therapy and its course. Throughout treatment, therapists should focus on patients’ strengths, such as resilience and optimism, and social supports, including friends and family. Given the importance of family, the use of multiple family groups can be effective in treatment for African Americans affected by ADHD. Different family members may come together with other families to learn and support one another. Clinicians should also be sensitive to gender alliance, as well as draw on the individual’s religion if that may be beneficial.

Psychopharmacology. Psychopharmacology is a vital part of treatment for ADHD, and many factors must be taken into consideration when assessing each patient’s case. Clinicians must recognize that, in general, African Americans have low utilization of stimulants, which may stem from mistrust or fear of addiction.4 Nonstimulant medications may be warranted for patients who are unable to tolerate the side effects of stimulants or for patients who have substance abuse concerns. Medical history should also be considered.

Conclusion

To better diagnose and treat African American adults with ADHD, clinicians must understand the mental health field from a cultural and historical perspective as it relates to African Americans. Environmental and sociocultural dynamics may influence the behaviors that are associated with ADHD. A multifaceted approach to both diagnosis and therapy for ADHD is needed. Clinicians should involve family members, significant others, or friends, as appropriate, to support patients’ chosen treatment, which may include psychotherapy, medication, or both. Importantly, clinicians must recognize that family can include non–blood relatives. Throughout treatment, culturally sensitive clinicians must avoid stereotyping and develop the capacity to assess patients’ strengths, not merely their deficits. These strategies can help clinicians overcome cultural issues and develop trust when working with African American patients.

Clinical Points

Understand how the history of racism within the field of psychiatry affects some African Americans today

Use a multifaceted approach to diagnose ADHD in African American adults using DSM criteria, the clinical interview with patient background, and informant reports

Treat adult ADHD with appropriate psychotherapy or psychopharmacology and family/social support